1. By
SURASARIT KHAWLAOR
1

2. INTRODUCTION
Disadvantage of theophylline
 Side effect
 Inconvenience of monitoring
blood levels
Advantage
 Not expensive
 Antiinflammatory &
immunomodulatory effects
Disadvantage of montelukast
 More expensive
Advantage
 Not requiring titration
 Not monitoring blood levels
2

3. INTRODUCTION
Reason for this research
Theophylline as add-on therapy to ICS shown
oBenefit in
oCons in
Meta-analysis have questioned efficacy of LTRA in asthma
therapy when added to ICS
Not comparing effectiveness of these 2 oral agents
3

4. INTRODUCTION
Objective
To compare effectiveness of low-dose theophylline and
montelukast for poorly controlled asthma patients
focused on
Primary outcome : asthma control by measuring
rate of episodes of poor asthma control (EPACs)
Secondary outcomes : ASUI, AQLQ, ACQ scores
pre & post-BD spirometry
4

5. INTRODUCTION
5

6. INTRODUCTION
6
for patients with moderate asthma & persistent
symptoms : low –dose inhaled budesonide with
theophylline & high-dose inhaled budesonide
produced similar benefits

7. INTRODUCTION
7

8. INTRODUCTION
8

9. INTRODUCTION
9
LTRA, but low-dose theophylline,
conferred significant additive
antiinflammatory effects to therapy
with low-dose inhaled
corticosteroid but not with
medium-dose

10. PROTOCOL
10

11. PROTOCOL
 Randomized, double-masked, placebo-controlled trial
 Participants from 19 centers in American Lung
Association Clinical Research center
 Age >= 15 yrs., physician-diagnosed asthma
 Prescribed daily asthma medication for >= 1 yr
 FEV1 >= 50% of predicted values
 Poor asthma control (by score >= 1.5 on ACQ)
11

12. PROTOCOL
 Exclusion criteria
Use oral corticosteroids, LTRA, theophylline within 4 wk
preceding enrollment
Current or former smokers with 20 pack-year or more
smoking history
Other significant illness
12

13. PROTOCOL
 Primary outcome
Measured by annualized rate of EPACs of following events
Decrease of peak expiratory flow > 30% of personal best for
>=2 consecutive days
Use of bronchodilator rescue medication over baseline by > 4
metered-dose inhalations ( or 2 nebulizer treatments) in 1 day
Oral corticosteroid treatment of asthma
Unscheduled asthma health care visit to physician,
emergency, hospital
13

14. PROTOCOL
Objective (cont.)
Secondary outcomes : ASUI,
AQLQ,
ACQ scores
pre & post-BD spirometry
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15. PROTOCOL
15
telephone 2
wk after Rz to
assess
compliance,
S/E, asthma
control
adherence
assessed by diary,
plasma theophylline
& montelukast at 1,
6 Mo

16. PROTOCOL
16

17. PROTOCOL
17

18. ASUI
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19. ASUI
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20. AQLQ
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21. RESULTS
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22. FLOWCHART
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23. FLOWCHART
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24. Baseline Characteristics
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25. Baseline Characteristics
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26. Adherence to therapy
Self-report adherence
84% for theophylline
88% for montelukast & placebo
Measured adherence by plasma drug concentration that
exceeded lower limit
Theophylline > 2mg/L (6.82.6 at 4 wks, 6.22.7 at 24 wks)
montelukast > 5ng/ml (123163 at 4 wks,125157 at 24 wks)
Termination : loss F/U, adverse events, withdrawal of
consent, other
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27. Adverse Events
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28. EPACs
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29. PROTOCOL
29

30. EPACs
 Subgroup analysis of adherence patients only
Defined by detectable 24-wk drug concentration
Not show significant improvement in EPACs for
theophylline or montelukast compare with placebo group
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31. Asthma Symptoms
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not statistically different in
either treatment group
compared with placebo

32. Lung Function
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33. PROTOCOL
33

34. Lung Function
 Overall prebronchodilator FEV1 was improved in both
theophylline & montelukast group
 Overall postbronchodilator FEV1
By theophylline was significant VS placebo
By montelukast trends to be similar but smaller
 Pre & postbronchodilator FVC were not significant
improved
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35. Lung Function
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36. Influence of ICS Use
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37. PROTOCOL
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38. Influence of ICS Use
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39. DISCUSSION
39

40. DISCUSSION
1.Primary outcomes
Use rate of EPACs because relevant to quality of life, cost
medical care, goal of asthma care under current practice
guideleines
Neither theophylline nor montelukast had additional benefit
in reducing EPACs, reducing asthma symptoms or
improving quality of life compare with placebo
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41. DISCUSSION
2.Secondary outcomes
 Both theophylline & montelukast improved prebronchodilator
spirometry, but only theophylline improved FEV1 after
bronchodilator  theophylline augment bronchodilator
effect (changes so small 0.08-0.09 L uncertain clinical
importance
41

42. DISCUSSION
3.subgroup analysis
 Theophylline reduced both event rates and symptoms in
patients with asthma who were not using ICS
4.Adherence was good in all treatment group (by diary self-report
at 4, 24 wks) but blood concentrations, at 24 wks, were absent
40% of both theophylline & montelukast group
5.Adverse effects were higher in theophylline group than in
montelukast group
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43. Researcher Comment
• Theophylline has antiinflammatory properties including
Inhibition of neutrophil migration
Inhibition of neutrophil,lymphocyte,monocyte
activation
Production of antiinflammatory cytokine IL-10
Inhibition of inflammatory mediators
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44. Researcher Comment
• Low-dose theophylline reduce airway eosinophilia in patients
with asthma, even in absence of bronchodilation response
• Reduction in expired nitric oxide concentrations
Lim S. et al. Am J Respir Crit care Med 2001; 164: 273-276
• Anti-inflammatory effects is activation of histone deacetylase
o Histone deacetylase, component of pathway by which corticosteroids are
believed to inhibit proinflammatory gene expression, and its activity is
reduced in some patients with asthma, especially cigarette smokers
Kazuhiro Ito et al. Am J Respir Crit Care Med 2002; 166: 392-396
44

45. Researcher Comment
• Peripheral blood mononuclear cells were obtained from 24
asthmatic subjects  left in a resting state or stimulated
with either mitogens (phytohemagglutinin, lipopolysaccharide)
or antigen (tetanus, cat) ĉ or ŝ presence of theophylline
(15 g/dL)
• Supernatants were collected & evaluated for cytokine
concentration by ELISA
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46. Researcher Comment
46

47. Researcher Comment
47
1.theophylline did not inhibit production of
allergenic cytokines (IL-4)
2.Statistically significant inhibition of IFN-
synthesis was observed
3.Theophylline have anti-inflammatory
effects on cytokine produced by
mononuclear phagocytic cell

48. Researcher Comment
48
PJ Barnes. Am J Respir Crit Care Med 2003; 167: 813-818

49. Researcher Comment
 He hypothesized that pt. using ICS may benefit by
addition of low-dose theophylline more than those not
using
He stratified participants by use of ICS  participants
assigned to theophylline who not using ICS had both
statistically & clinically significant in asthma control &
symptoms  reason not clear
But subgroup who not use ICS is so small need further
investigation
49

50. Researcher Comment
 ICS are generally considered to be mainstay of
antiinflammatory controller treatment in asthma but theophylline
,although mild bronchodilator, is only marginal benefit in
asthma symptom control for pts. with asthma already treated
with ICS
 Montelukast, like theophylline, no additional beneficial effect on
asthma control as measured by lung function variability, -
agonist use, health care use
Subgroup of pts, not taking ICS at baseline  montelukast did not
improve asthma control
50

51. Researcher Comment
 Most guidelines recommend LABsA as add-on treatment when
ICS do not provide adequate asthma control
 But some studies raised questions about safety of LABA
,some have suggested low-dose theophylline may be
alternative to LABAs when ICS alone do not adequately control
asthma 1
 However, no studies compared LABAs with low-dose
theophylline until now
51
1 Martinez FD. N Engl J Med 2005;353: 2637-2639

52. Researcher Comment
52

53. Researcher Comment
PRO : Shamsah Kazani, James H.,Ware & Jeffrey,
M.Drazen
2 prospective randomzed studies that examined asthma-related
mortality
UK’s Serevent National Surveillance study (SNS)
12 death from 16,787 pts. (tx over 16 wks) compared with 2 death of
8,393 pts. In control group
USA’s Salmeterol Multicenter Asthma Research Trial (SMART)
13 death in 13,176 pts. (tx 28 wks) compared with 3 death of 13,179
pts. In control group
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Shamsah KAZANI et al. PRO/CON debate. Respirology 2010: 15: 881-886
1.approximately 1 in 700 patient years of
treatment
2.Both SMART & SNS were inadequately
powered to study the safety of LABA
when used in combination with ICS

54. Researcher Comment
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Randomized trial to study the safety of LABA
when combined with ICS
GlaxoSmithKline claims that it is not feasible to
study in randomized trial because of requiring
approximately 700,000 subject per group
The authors propose that 50,000 pts. With
moderate or severe asthma should enrolled in
randomized double-blind trial (half treated with
ICS & other half treated with ICS plus LABA)
Shamsah KAZANI et al. PRO/CON debate. Respirology 2010: 15: 881-886

55. Researcher Comment
55
CON : Malcolm R. Sears
FDA meta-analysis involving 110 trials & 60,954
subjects (Leavenson M.) show RD (risk differences)
for LABA VS non-LABA, ignoring ICS use ;RD was
 0.40 (95% CI: 0.11–0.69) /1000 for asthma-related death
 0.57 (95% CI: 0.01–1.12) for asthma-related death or
intubation
 2.57 (95% CI:0.90–4.23) for asthma-related hospitalization
 all three end-points, 2.80 (95% CI: 1.11–4.49)
Shamsah KAZANI et al. PRO/CON debate. Respirology 2010: 15: 881-886

56. Researcher Comment
56
CON (cont.)
Stratified by ICS use
 6 for patients receiving LABA without mandatory
randomized ICS  RD was 3.63 (95% CI:1.51–5.75)
 among patients receiving LABA with mandatory ICS
 RD was non-significant (0.25: 95% CI: -1.69–2.18)
per 1000 subjects
From those data the author calculated sample size
for receiving enough power on death (LABA plus
ICS) about exceed 4 million subjects ! (mega-trial)
Shamsah KAZANI et al. PRO/CON debate. Respirology 2010: 15: 881-886

57. Researcher Comment
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CON (cont.)
In contrast to the 1970s epidemic of deaths in
NewZealand associated with SABA (fenoterol)
 no epidemic of asthma deaths has occurred
after introduction of LABA
Sears MR, Taylor DR. Drug Saf. 1994; 11: 259–83
Shamsah KAZANI et al. PRO/CON debate. Respirology 2010: 15: 881-886

58. Researcher Comment
58
CON (cont.)
Weatherall et al. reported no deaths among
22,600 asthmatics treated with salmeterol plus
fluticasone in a single inhaler
Weatheral M. et al. Thorax 2010; 65(1): 39-43
Sears and Radner reported no excess deaths
among 14,346 asthmatics treated with formoterol
plus budesonide in a single inhaler as
maintenance and reliever therapy
Sear MR, Radner F. Respir Med. 2009; 103: 1960-8
Shamsah KAZANI et al. PRO/CON debate. Respirology 2010: 15: 881-886
1.No adverse event signal coming
from data in which LABA & ICS
have been used in single inhaler
2.New appropriately designed
study addressing mortality is
neither required nor feasible

59. Researcher Comment
 one previous trial has directly compared efficacy of theophylline
with LTRA Dempsey and colleagues
The added antiinflammatory effects of zafirlukast and
theophylline, measured with either exhaled nitric oxide or
methacholine reactivity were only present with low-dose but
not with mediumdose ICS
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60. THANK YOU FOR YOUR
ATTENTION
60